A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action?
A. Assertively instruct the client to stop punching the wall.
B. Encourage the client to write down feelings in a journal.C. With the help of staff, initiate seclusion protocol.
D. Ensure adequate physical space between the nurse and the client.
D
To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space.
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